Intramedullary nails (IMN) have revolutionized the treatment of tibial shaft fractures, allowing for reliable bone healing, early mobilization and reproducible return to function.1–3 With excellent results in the tibial diaphysis, IMN can also be used in both the proximal and distal thirds of the tibia with comparative results.4–7 However, with stronger deforming forces at the proximal and distal ends of the tibia, anatomic restoration can be more complex and often requires technical adjuncts to achieve appropriate length, alignment, and rotation.4,8–11
When used in combination with IMN, provisional or adjunct permanent plate fixation can be an important tool in obtaining and maintaining fracture reduction.4,12–14 Similarly, nail and plate combination (NPC) fixation can also be used for distal third tibia fractures but with important differences. In this article, we will discuss these specific differences and provide the tips, tricks, and pitfalls of NPC in the distal tibia.
ANATOMIC AND BIOMECHANICAL CONSIDERATIONS OF IMN IN THE DISTAL TIBIA
Anatomically, the distal tibia is not all that different from the proximal end. Similarly, bony anatomy transitions from the diaphysis into a larger metaphyseal region followed by an articular block. Soft tissue coverage is sparse medially and more robust posteriorly and laterally. However, looking closely, notable differences in the deforming forces and surrounding anatomy are important when planning definitive fixation.
Unlike the proximal tibia, the fibula (and the ankle joint overall) plays a more crucial role in achieving fracture stability in the distal tibia. Stabilization of the fibula before placing tibial fixation can aide in restoration of tibial length, alignment, and rotation, especially when the syndesmotic and tibiofibular ligaments are intact.15 Furthermore, in the distal tibia, the primary deforming forces in the distal tibia occur as a result of the extrinsic, antagonistic relationship between the dorsiflexor and plantar flexor of the foot. Foot position is crucial, as plantar flexion will create an apex anterior fracture deformity, and dorsiflexion, an apex posterior deformity. This relationship is an extremely important point to consider when planning a fixation construct. With large forces acting at the fracture site because of simple foot and ankle motion, applying the appropriate density of fixation becomes mandatory to avoid construct failure. In addition, building a stable fixation construct is even more important during IMN because of the lack of bone-implant contact in the large volume, cancellous metaphyseal region.1
Biomechanically, using IMN alone in the metaphyseal region of the distal tibia can become problematic. Especially, without appropriate fixation stability, the “windshield-wiper” action that occurs in the metaphyseal flare, can lead to high failure rates and unacceptable deformity. Early IMN designs had limited fixation options, which resulted in early failure.16,17 Subsequent studies led to a better understanding and evolution of nail design.16,18–20 Noting unacceptably high failure rates with only 1 distal locking screw, studies confirmed a near 10-fold increase in the failure rate when compared with that using 2 locking screws.16,20 This led to 2 very important design features that were added to IMN as follows: more distal screw options and multiplanar screw options. However, are these advances enough to offer immediate weight bearing without failure of fixation?
Biomechanical studies have shown the superiority of multiplanar fixation over biplanar fixation.15 Attal et al compared the 2 fixation constructs and the need for additional fibular plating in the setting of immediate weight bearing. The authors' results noted that with multidirectional screws, fibular plating was not required, whereas with a biplanar locking screw configuration, fibular plating significantly increased construct stability.15 Similarly, Chan et al21 compared biplanar fixation versus multidirectional fixation and even included a third arm that used biplanar fixation with a blocking screw. Here, the authors also concluded that multiplanar fixation offered the best construct in the weight bearing scenario.21
However, does this translate to the clinical setting? Although several published studies report comparable outcomes between IMN and plating, data and analysis and constructs are lacking.6,18,22–24 Often, however, the authors typically discuss failed constructs as having similar issues; a very distal fracture preventing the required fixation construct and/or a large bony defect that extends into the metaphysis causing the IMN to take a significant more amount of load that leads to failure. Here, in these specific scenarios is where NPC can be extremely helpful in achieving one's desired goals in restoring appropriate length, alignment, and rotation.
INDICATIONS FOR NPC IN THE DISTAL TIBIA: FROM NIGHT 1 TO REVISION FIXATION
In general, IMN advocates recommend taking advantage of the inherent, mechanical load sharing device and offer early weight bearing. Depending on the fracture location, NPC can be used not only to maintain reduction but also to provide additional stability to confidently start weight bearing earlier than that with IMN or a plate alone.4,5,12 In the proximal tibia, routine use of a supplemental plate can be used as a reduction aid before nailing.4,5,25 Although this may also be applied to the distal tibia, achieving and maintaining anatomic reduction is arguably (especially through an open wound) not as difficult and may not warrant routine adjunct plate placement. However, in the distal tibia, there are a few select clinical scenarios when adjunct plating and using NPC can be extremely helpful. More specifically, these situations include high-grade open fractures with a large zone of injury, fractures with large bony defects, and very distal fractures. By applying NPC, stable construct stability can allow for early weight bearing and avoid hardware failure. Here, we will review specific cases and techniques in utilizing NPC.
Case 1: A 34-Year-Old Male With Grade IIIB Open Distal Tibia Fracture
A 34-year-old male presented to the trauma slot after a motorcycle collision, going approximately at 80 miles per hour. Evaluation and radiographs revealed an isolated injury to the right lower extremity (Fig. 1A–B). The patient was taken to the operating room for urgent irrigation and debridement (I&D) and planned external fixation. Intraoperative debridement revealed an extensive zone of injury extending proximally to the proximal third of the tibia with severe damage to the anterior and lateral muscle compartments (Fig. 1A). Miraculously, the patient's gross neurovasculature remained intact; after debridement, extensive soft tissue and bone loss was demonstrated. Because of the extensive zone of injury, external fixator pin placement was placed as far away from the fracture as possible, leaving the fracture grossly unstable, despite multiplanar fixation. Furthermore, because of the extensive soft tissue loss and expected need for frequent return trips to the operating room, bar placement over the injury was suboptimal. At this juncture, supplemental provisional fixation was applied to both the tibia and fibula to provide temporary fracture stability. A bead pouch was placed and postoperative radiographs revealed acceptable reduction (Fig. 1C–D).
Repeat I&Ds were performed every 48 hours, when on postinjury day 5, the wound was deemed clean enough to place definitive fixation. At this juncture, repeat debridements had left an approximate 3-cm anterolateral bony gap with no cortical apposition. The fibular plate helped to maintain gross length and alignment, and the tibial one-third tubular plate was removed and replaced with a stronger, 10-hole 2.7-mm reconstruction plate, fixed with unicortical screws. Now, with desired fracture reduction maintained, a tibial IMN as placed, again, with a new bead pouch (Fig. 1E–F). Forty-eight hours later, repeat I&D was performed, and an antibiotic cement spacer was placed in the bone defect (as a planned, Masquelet first stage), followed by definitive soft tissue coverage with a free flap (Fig. 1G–H). Once cleared by plastic surgery to allow for ambulation, the patient was made toe-touch weight bearing with an assistive device until bone grafting (stage 2 of the Masquelet—removal of cement spacer, grafting with bone marrow aspirate and crushed cancellous chips), which was performed 6 weeks after the free flap (Fig. 1I). Immediately following bone grafting, the patient was made weight bearing as tolerated with an assistive device and went on to uneventful healing (Fig. 1J). Currently, at 10 months' follow-up, the patient walks without an assistive device and reports minimal pain.
Case 2: A 42-Year-Old Female With Distal Tibia Nonunion
A 42-year-old female presents as a restrained driver following a motor vehicle accident. Workup revealed an isolated grade 1 open, extra-articular left distal tibia fracture (Fig. 2A–B). Skin perforation was located laterally and was extended to reveal a relatively small zone of injury, however, with significant comminution and devitalized bone. Following thorough I&D, the fibula was stabilized through the lateral extension of the wound, followed by reduction and tibial IMN (Fig. 2C). With a distal fracture and significant bone loss posteromedially, the patient was made non–weight bearing for that affected extremity. The patient was lost to follow-up and presented at the 3-month time point complaining of pain and instability. The patient reported she was nonadherent to weight bearing precautions and had been walking on the affected limb. Radiographs revealed nonunion and hardware failure (Fig. 2D). Infection workup, including bone biopsy, was negative, and definitive fixation was planned.
Because the patient was nonadherent to instructions at the time of her index procedure, this time, the goal was to try and perform a single, definitive surgery. Thus, a modified fibula-pro-tibia procedure (using NPC) was planned with the goals of creating a stable construct strong enough to not only allow for immediate weight bearing but also to withstand the cyclic loading of ambulation until bony union.26,27
Using minimally invasive percutaneous technique, a small 2-cm incision was made on the medial side to clear out the nonunion tissue from the medial side and remove the broken distal locking screws. Next, the previously used anterolateral incision was used to gain access to the fibula and the lateral tibia to remove the nonunion tissue as well as decorticate and prepare the tib–fib junction for bone grafting and fusion. A dynamic compression plate was placed with provisional unicortical fixation to restore the medial column and provide facile exchange nailing. Final screw fixation within the plate most importantly included two screws that linked the nail to the plate and the final, distal screw that crossed into the fibula for supplemental fixation (Fig. 2E). Bone graft (bone marrow aspirate and cancellous chips) was placed in the central compartment from the lateral incision to fill the prepared tib–fib junction. The patient was made weight bearing as tolerated and on discharge, only followed up for a single postoperative visit 3 months later, clinically and radiographically healed, complaining of mild ankle stiffness (Fig. 2F).
DISCUSSION AND SUMMARY
The NPC technique can be very useful in unique scenarios involving complex distal tibia fractures. In case 1, initial provisional plating helped to achieve fracture stability when supplementing with external fixation and setup a facile environment for subsequent tibial IMN placement. Here, using NPC not only provided construct stability needed to avoid any windshield-wiper effect but also made future bone grafting procedures easier. Case 2 provides the perfect example of what can happen with very distal tibia fractures despite biplanar and fibular fixation. In this revision situation, again, the medial cortical plate similarly aided in maintaining reduction and facilitating easy IMN placement. However, the real benefit came with the linked NPC construct, which confidently allowed for immediate weight bearing, promoting union and avoiding fixation failure.
In summary, while the indications can be rare, NPC can be a useful and reliable technique in very distal tibia fractures. Applying the NPC technique can aide in obtaining and maintaining reduction before IMN placement but, more importantly, can provide a stable construct that can confidently allow immediate weight bearing and resistance against the windshield-wiper motion that can preclude failure.
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